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A 1-year-old boy was brought to the emergency department because his parents were concerned that he might have ingested a pencil-tip eraser. His parents did not witness the event, but they reported that they had heard choking sounds for a few seconds, followed by 1 episode of vomiting. The child had no history of dyspnea, and he appeared well after vomiting. Upon physical examination, the child was afebrile, and he did not show symptoms of severe infection or signs of respiratory distress. There was a small bruise on the patient's left tonsil and a 2-mm laceration on his tonsillar pillar. Auscultation confirmed normal breath sounds.
A radiograph of the neck showed diffuse subcutaneous emphysema consistent with a puncture wound (Figure 1), and a radiograph of the chest showed emphysematous collections of air along the fascial planes of the neck (Figure 2). A computed tomography scan (Figure 3) showed extensive emphysematous collections surrounding the carotids. The patient received a diagnosis of subcutaneous emphysema of the neck and pneumomediatinum secondary to an oropharynx puncture wound.
After consultation with an otolaryngologist, the patient was admitted to hospital and received empiric antibiotic therapy. The patient's condition was monitored by one-to-one nursing in case of airway compromise. The results of a contrast study using a water-soluble agent showed no active perforation of the esophagus. Our patient was discharged 3 days after admission. At a 6-month follow-up visit, there were no complications or concerns.
Although pharyngeal perforation is rare in children, perforation can result when a child swallows a foreign object.1 Pharyngeal trauma can be associated with trivial injuries that are often unwitnessed, and the patients often present with incomplete histories. A tragic, but important, cause of pharyngeal trauma is child abuse.2 Inconsistencies in the patient's history may alert clinicians to this serious problem. A delay in the recognition and management of pharyngeal trauma can lead to avoidable complications such as retropharyngeal abscess, mediastinitis and airway compromise.
Footnotes
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This article has been peer reviewed.
Competing interests: None declared.